Notice of Privacy Form

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Acknowledgment of Notice of Privacy Practices

Patient First Name

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Patient Last Name

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DOB:

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I hereby acknowledge that i recieved Mark N. Scheinberg, M,D,P,A. Notice of Privacy Practices

Signature of Patient or Representative

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Date

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Witness

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I am authorizing Dr. Mark Sheinberg's office to release Medical information to the following:

Name

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DOB

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Relationship to Patient

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Name

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DOB

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Relationship to Patient

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Name

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DOB

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Relationship to Patient

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Board Certified Obstetrics - Gynecology Vagina Reconstruction - Natural Hormones

Name

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DOB

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Date

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Allergies

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Medications

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Covid-19 Vaccines

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Date

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Family History (example: Father-High Blood Pressure, Colon Cancer, Diabetes, Stroke, Cholesterol)

Mother

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Father

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Sister(s)

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Brother(s)

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Maternal Grandfather

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Maternal Grandmother

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Paternal Grandfather

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Paternal Grandmother

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Social History

Smoking Status

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Tobacco - Years of Use

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Occupation:

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Education

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Marital Status

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Do you live alone or Do you live with others?

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Number of Children

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Are you currently employeed?

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Exercise Level:

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Diet:

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Smoking Pre-pregnancy:

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Smoking How Much?

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Has Smoked Since Age?

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Alcohol Pre-pregnancy:

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Caffeine Intake:

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Illicit drugs Pre-pegnancy?

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Illicit Drugs Never:

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Illicit Drugs - Years of Use

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Sexual Orientation:

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Is anesthesia consult planned?

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Is blood transfusion acceptable in an emergency?

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Live with cats/exposure to cat litter.

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Occupational Health Risk

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Passive Smoke Exposure:

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Passive Smoke Exposure:

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Sexually Active:

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Protected Sex Always

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Performs Monthly Self Breast Exam

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Surgical History (ex: Breast Implants, Hysterectomy, Appendectomy)

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Date

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Date

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Date

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Date

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Gynecological History

Date of last Pap Smear:

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HPV Vaccine

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Sexually Active

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Sexually Problem

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Sexually Transmitted Disease

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Age at First Child:

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On BCP's (birth control) at conception:

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Current Birth Control Method

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Desired Birth Control Method

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Most Recent Mammogram

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History Of Abnormal Pap

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Is your Last Menstrual Period?

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Flow

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Frequency of Cycle

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Other

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Menses(Period) Monthly

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Age of First Period

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If Post Menopause, age at menopause

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Date of Last Colonoscopy

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Date of Last Mammogram

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Date of Last Menstrual Period

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Hormone Replacement Therapy

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Most Recent Bone Density

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Post Menopausal Bleeding

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Obstetric History

Total Number Of Pregnancies

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Full Term Number

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Premature Number

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Abortion Number

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Miscarriage Number

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Ectpoic Number

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Multiple Births

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Numbers of Living Childrens

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Past Medical History

Abuse / Domestic Violence

Acid Reflux (GRED)

Acne

Anemia

Anesthesia Complications

Anxiety Complications

Arthritis

Asthma

Birth Defects or Inherited Disease

Blood Transfusion

Breast Cancer

Breast Problem

Cancer

Depression

Diabetes

Eating Disorder

Eczema

Endometriosis

Fibromyalgia

GI Problems

Headaches

Heart Disease

Heart Problems

Hepatitis

High Cholestrol

Hypertension

Infertilty

Kidney Diseases

Kidney or Bladder Problems

Lung Diseases

Osteoporosis

Other

Ovarian Cancer

Polyps

Pre-Eclampsia

Psychiatric Illness

Stroke

Thrombphilia

Thyroid Problems

Varicosities

No To All

Pelvic Health Survey

Todays Date

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Patient Name

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Age:

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Sex

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Bladder

How often do you leak urine?

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We would like to know how much urine you think leaks. How much urine do you usually leak (whether you wear protection or not)? Check one box.

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Overall, how much does leaking urine interfere with your everyday life? Please circe between 0(not at all) and 10(a great deal).

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When does urine leak?

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Do you wear diapers, pads, or panty liners because of leaking?

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Are you bothered by the number of times per day you have to empty your bladder?

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Do you wake up at night to empty your bladder?

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If yes, How many times?

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Do you feel you have to rush to the toilet to avoid an accidental leak?

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Bowel

Do you accidentally leak stool?

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Do you have in strain to have bowel movement?

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Do you have gas when you do not want to?

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Gynecological:

Do you experience pelvic pain?

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Do you have a feeling of a "ball" in your vagina?

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Hysterectomy?

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Vaginal Dryness?

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Number of Vaginal Deliveries

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Number of Cesarean Section

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